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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600865
Report Date: 06/10/2022
Date Signed: 06/10/2022 03:24:37 PM

Document Has Been Signed on 06/10/2022 03:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:VAGTHOL'S RESIDENTIAL CARE CENTERFACILITY NUMBER:
197600865
ADMINISTRATOR:CHAMU-NESTOR, FRANCISCAFACILITY TYPE:
735
ADDRESS:418 N. MARIPOSATELEPHONE:
(818) 562-1447
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY: 6CENSUS: DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:CHAMU-NESTOR, FRANCISCATIME COMPLETED:
03:37 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1-year visit focusing on COVID-19 Infection Control Practices. LPA met with Manager Eudia Seisa and Administrator Francisca Chamu-Nestor arrived a short time later and LPA explained the purpose of the visit. Home is specialized home. The home has 2 ambulatory clients, none have a restricted health care condition and all clients are over 60 years of age. Facility is one story home located in a residential area consisting of 1 shared room and 4 private rooms and 1 staff room and one staff office in detached garage, 2 bathrooms, living room, dining room, backyard patio area, and detached garage. The last fire drill was completed on April 4, 2022. Administrator certificate expires 10/08/2023

The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote hand washing, cough/sneeze etiquette, and physical distancing.
· Facility has designated isolation room.
· Five (5) resident rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· All client rooms were not equipped with alcohol-based hand sanitizer but available throughout the facility
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
· No deficiencies cited

Exit interview was conducted with Administrator Francisca Chamu-Nestor. A copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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